CLINICAL ACTIONS:

While multiple disciplines are required to diagnose and manage both benign breast disorders and breast cancer, the most important interaction with a patient remains the initial office visit

• Obtain careful history of all breast related symptoms including duration, changes in symptoms over time, presence and color of nipple discharge
• Identify risk factors for breast cancer, including
  • Advanced age (over 65)
  • Positive family history
  • Age > 30 at first birth
  • Nulliparity
  • Never breastfed
  • Menopausal hormone therapy
  • Alcohol use (not clear what the threshold is)
• Visually inspect and manually palpate the breasts, axillae and supraclavicular nodal regions
• Clinical documentation of any mass should include size, consistency, distance from areola and clock position in the breast
• Diagnostic imaging includes ultrasonography, mammogram or digital tomosynthesis
  • Manage breast lesion based on age, clinical suspicion, Breast Imaging Reporting and Data System (BI-RADS) and other imaging findings
  • Ultrasound can differentiate solid from cystic lesions
• Histology can be obtained from fine needle aspiration (FNA), core needle biopsy or excisional biopsy, procedures that are usually performed by radiologists or surgeons
• Women 30 years and older with palpable mass – mammogram followed by ultrasound, if necessary
• Women under 30 years with a palpable mass  – ultrasound is the primary imaging modality
  • If ultrasound imaging is suspicious for cancer, follow up with tissue biopsy
  • If ultrasound does not suggest malignancy but clinical suspicion remains, perform a diagnostic mammogram
  • If ultrasound imaging suggests a benign cyst or a benign appearing solid mass options are to follow-up with physical exam +/- ultrasound/diagnostic mammogram every 6-12 months for 1-2 years to assess stability
• Women presenting due to a mass that cannot be palpated by patient or clinician should not be dismissed and must be followed up with imaging

SYNOPSIS:

Benign breast lesions can be categorized as nonproliferative (breast cysts), proliferative without atypia (fibroadenoma, intraductal papilloma, fibrocystic change) which may carry a small risk (1.5 to 2 times above general population) for breast cancer and atypical hyperplasia (ductal or lobular). The latter category carries a substantially increased risk of subsequent invasive cancer in either breast (see ‘Related ObG Topics’, below). Nipple discharge is common, and usually benign. Unilateral, uniductal and spontaneous discharge carries a higher risk of malignancy and should be further evaluated with ultrasound.

KEY POINTS:

• Women 30 years of age or older with palpable breast masses shown to be solid on imaging should be biopsied if BI-RADS 4-5, or if BI-RADS 1-3 with high clinical suspicion
  • Observation an option if BI-RADS 1-3 and low clinical suspicion (see ‘Related ObG Topics’ below)
• Women with simple cysts can undergo routine follow-up
  • Consideration for biopsy should be given to complicated cysts with BI-RADS 1-3
  • Complex cysts with BI-RADS 4-5 on imaging require biopsy
• When common skin problems are identified in the breast such as psoriasis, eczema, contact dermatitis, Candida infections, standard treatment should be used
• Skin edema, warmth and erythema as well as ulceration, nipple retraction/crusting/scaling should raise concerns for malignancy and require tissue diagnosis
• ICD-10 CM Code N63 (breast lump)

Learn More – Primary Sources:

ACOG Practice Bulletin No 164: Diagnosis and Management of Benign Breast Disorders

ACS: Breast Cancer Prevention and Early Detection

Benign Breast Disease in Women

Common Breast Problems

Related ObG Topics:

Mammography Guidelines for Average-Risk Women

BI-RADS: Standardizing Breast Imaging and Reporting 

Atypical Hyperplasia of the Breast: Follow up and Management

Breast Cancer Risk Assessment for Average Risk Women – The 5-Year Risk Score

NCCN Update: BRCA1/2 Testing Criteria